Basic Information
| Provider Information | |||||||||
| NPI: | 1447675285 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PRECISION HEALTH CARE SERVICES | ||||||||
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| Mailing Information | |||||||||
| Address1: | 311 JUDGES RD | ||||||||
| Address2: | BLDG 4 | ||||||||
| City: | WILMINGTON | ||||||||
| State: | NC | ||||||||
| PostalCode: | 284053651 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9107916767 | ||||||||
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| Practice Location | |||||||||
| Address1: | 311 JUDGES RD | ||||||||
| Address2: | BLDG 4 | ||||||||
| City: | WILMINGTON | ||||||||
| State: | NC | ||||||||
| PostalCode: | 284053651 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9107916767 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 03/04/2014 | ||||||||
| LastUpdateDate: | 07/29/2014 | ||||||||
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| AuthorizedOfficialLastName: | FETTER | ||||||||
| AuthorizedOfficialFirstName: | MATT | ||||||||
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| AuthorizedOfficialTitleorPosition: | CORPORATE DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 2523271815 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103T00000X | NC | Y | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Psychologist |
ID Information
| ID | Type | State | Issuer | Description | 024MW | 01 | NC | BCBS | OTHER | 3410033 | 05 | NC | MEDICAID |